APPEAL TO BOARD OF VETERANS’ APPEALS

1 APPEAL TO BOARD OF veterans APPEALSForm Approved: OMB No. 2900-0085 Respondent Burden: 1 in filling out this (LastName,FirstName,MiddleInitial) (Includeprefix)3. INSURANCE FILE NO., OR LOAN I AM THE:VETERANOTHER(Specify)VETERAN S WIDOW/ERVETERAN S CHILDVETERAN S PARENT6. MY ADDRESS IS:(Number&StreetorPostOfficeBox,City,St ate&ZIPCode) (IncludeAreaCode) (IncludeAreaCode)7. IF I AM NOT THE VETERAN, MY NAME IS:(LastName,FirstName,MiddleInitial)8. APPEALS hearing. DO NOT USE THIS FORM TO REQUEST A HEARING BEFORE A VA REGIONAL OFFICE HEARING one (and only one) of the following boxes:I DO NOT WANT A BVA WANT A BVA HEARING IN WASHINGTON, WANT A BVA HEARING AT A LOCAL VA OFFICE BEFORE A MEMBER, OR MEMBERS, OF THE BVA.

2 (Not available at Washington, DC, or Baltimore, MD, Regional Offices.) :(Besuretoreadtheinformationaboutthisblo ckinparagraph6oftheattachedinstructions. )I WANT TO APPEAL ALL OF THE ISSUES LISTED ON THE STATEMENT OF THE CASE AND ANY SUPPLEMENTAL STATEMENTS OF THE CASE THAT MY LOCAL VA OFFICE SENT TO :(Listbelow.) (Continue on the back, or attach sheets of paper, if you need more space.)11. SIGNATURE OF PERSON MAKING THIS APPEAL12. DATE13. SIGNATURE OF APPOINTED REPRESENTATIVE, IF ANY( instructions.)14. DATEVAFORMJAN 1998(RS)9 JetForm5. TELEPHONE :(Besuretoreadtheinformationaboutthisblo ckinparagraph6oftheattachedinstructions. )We are required by law to give you the information in this box.

3 Instructions for filling out the form follow the :VAmaynotconductorsponsor,andtheresponde ntisnotrequiredtorespondto,thiscollectio nofinformationunlessitdisplaysavalidOffi ceofManagementandBudget(OMB) (2900-0085).Publicreportingburdenforthis collectionofinformationisestimatedtoaver ageonehourperresponse,includingthetimefo rreviewinginstructions,searchingexisting datasources,gatheringandmaintainingtheda taneeded, ,includingsuggestionsforreducingthisburd en,toVAClearanceOfficer(045A4),810 VermontAve.,NW,Washington, (d)(3), APPEALS (BVA). , ( )andVA sconfidentialitystatue( ), (a) (b), , s"systemsofrecords" ,ifyoulaterappealtheBVA sdecisioninyourcasetothatcourt;disclosur etoamedicalexpertoutsideofVA, ,toaskforanexpertmedicalopiniontohelpdec ideyourcase;disclosuretolawenforcementpe rsonnelandsecurityguardsinordertoalertth emtothepresenceofadangerousperson;disclo suretolawenforcementagenciesshouldtheinf ormationindicatethattherehasbeenaviolati onoflaw;disclosuretoacongressionaloffice inordertoansweraninquiryfromthecongressi onalofficemadeatyourrequest.

4 AnddisclosuretoFederalgovernmentpersonne lwhohavethedutyofinspectingVA :Wehavetriedtogiveyouthegeneralinformati onmostpeopleneedtocompletethisforminthes einstructions,butthelawaboutveterans , , APPEALS (BVA) ServiceOrganizations(VSOs)willrepresenty ouatnochargeandmostpeople(morethan80perc ent) ,youmaypayalawyeror"agent"torepresentyou .(Seethereferencesinparagraph9.) who can represent ,calledfilinga"NoticeofDisagreement."Tha tofficethenmailedyoua"StatementoftheCase "(SOC) , ,youoryourrepresentativemustfilloutthisf ormandfileitwithVA."Filing" to file this form and paragraph 7 tells you where you file "yourlocalVAoffice"intheseinstructions,w emeantheVARegionalOfficethatsentyouthe"S tatementoftheCase" or, if you have moved out of the area served by that office, the VA Regional Office that now has your VA , APPEAL after you have read the SOC, you don t have to do , (a) You have one year from the day your local VA office mailed you the notice of the decision you are appealing.

5 (b) You have 60 days from the day that your local VA office mailed you the SOC. (c) Your local VA office may have sent you an update to the SOC, called a "Supplemental Statement of the Case" (SSOC). Under an opinion by VA s General Counsel, if that SSOC discusses evidence in your case that VA received within the one-year period described in paragraph 4(a) of these instructions, above, and if you have not already filed this form, then you have at least 60 days from the time your local VA office mailed you the SSOC to file it even though the one-year period has already ,calleda"simultaneouslycontestedclaim," "simultaneouslycontestedclaim"isacasewhe retwodifferentpeopleareaskingforthesamek indofVAbenefitandonewilleitherlose,orget less, , ask your representative or call your local VA , important.

6 Failing to file on time could result in you losing your right to ,writetoyourlocalVAoffice, ,VAwillusethepostmarkdatetodecidewhether youfiledtheform,ortherequestformore time to file it, on is easy to understand, we will go through the blocks where you might need some additional ,enteryourVAinsuranceor VA loan number here. For most kinds of cases, you will leave this block out this form for the person filing the APPEAL , fill in the information about that person, not yourself. Block 7 can be left blank if the person filing the APPEAL is the ,andonlyone, not you want an opportunity to appear personally before one or more members of the BVA to give them information aboutyourcase,and,ifso, ,BVAwillassumethatyouDONOT want a BVA ,youandyourrepresentative(ifyouhaveone)c antelluswhyyouthinktheBVAshouldact favorably on your APPEAL (present argument).

7 You can also tell us about the facts behind your claim and you can bring others (witnesses) to the hearing who have information to give the BVA about your case. At your option, you can submit more evidence at a hearing requested on this form. If you do ask for a hearing, it can be very helpful to have a representative assist you at the hearing. Here is specific information about each of the check boxes in block , :CheckboxBorboxCifyouwanttoappearinperso nbeforeamember,ormembers,oftheBVA to present your case. We have provided two different boxes because you can have your BVA hearing in one of two different places.

8 You can have your hearing at the BVA s offices in Washington, DC, or you can ask for a BVA hearing at your local VA office. In making your decision, you should know that VA cannot pay any expenses you (or your representative or witnesses) incur in connection with attending a hearing. Having your BVA hearing at your local VA office is usually less expensive for you, because you won t have as much expense for travel for yourself, your witnesses, and your representative. On the other hand, it sometimes takes longer to get your case added to the calendar for BVA hearings at local VA offices because BVA members conduct hearings in the field only during special trips.

9 You can check with your local VA office to get an estimate of how long it may be before your case could be scheduled for a BVA hearing (s)sittinginWashington,DC, , , ,contactyourlocalVAofficetosee if it is available in your area and inquire about proceduresHEARINGOFFICERHEARINGS:Ahearin gbeforealocalVAhearingofficer,insteadofb eforeamemberoftheBVA,is not a BVA hearing. You can request a local hearing officer hearing by writing directly to the regional office. DO NOT use this form to request that kind of hearing. If you do, it will delay your APPEAL . You should also know that requesting a hearing before a local VA hearing officer does not extend the time for filing this "issues" tried to accurately identify the issues and has listed them on the SOC and any SSOC it sent you.

10 If you think that your local VA office has correctly identified the issues you are appealing and, after reading the SOC and anySSOC youreceived,youstillwanttoappealitsdecis ionsonallthoseissues, check the second box if you check the first box. Check the second check box in block 9 if you only want to continue your APPEAL on some of the issues listed on the SOC and any SSOC you received. List the specific issues you want to APPEAL in the space under the second box. While you should not use this form to file a new claim or to APPEAL new issues for the first time, you can also use this space to call the BVA s attention to issues, if any, you told your local VA office in your Notice of Disagreement you wanted to APPEAL that are not included in the SOC or a SSOC.